Nursing Elites

1. A 3-month-old infant has been hospitalized with respiratory syncytial virus (RSV). What is the priority intervention?

• A. Administering an antiviral agent
• B. Clustering care to conserve energy
• C. Offering oral fluids to promote hydration
• D. Providing an antitussive agent when necessary

Correct answer: B

Rationale: The priority intervention for a 3-month-old infant hospitalized with respiratory syncytial virus (RSV) is clustering care to conserve energy. Infants with RSV often struggle to breathe and require rest periods to recover. Clustering care involves organizing nursing activities to allow for rest intervals, reducing the infant's energy expenditure and aiding recovery. Administering antiviral agents is not the primary intervention for RSV since it is a viral infection, and antiviral medications may not be effective against RSV. While offering oral fluids is crucial for hydration, it may not be the priority when the infant is having respiratory difficulties. Providing an antitussive agent when necessary can help with coughing but is not the priority intervention for managing RSV in this scenario.

2. Which best describes a full-thickness (third-degree) burn?

• A. Erythema and pain
• B. Skin showing erythema followed by blister formation
• C. Destruction of all layers of skin evident with extension into subcutaneous tissue
• D. Destruction injury involving underlying structures such as muscle, fascia, and bone

Correct answer: C

Rationale: A full-thickness (third-degree) burn involves the destruction of all layers of skin, including the epidermis, dermis, and extending into the subcutaneous tissue. This type of burn results in significant tissue damage and can appear pale, charred, or leathery. Choice A is incorrect as erythema and pain are more characteristic of superficial burns. Choice B describes a partial-thickness burn where the skin shows erythema followed by blister formation, involving the epidermis and part of the dermis. Choice D is incorrect as it describes a deeper type of injury involving structures beyond the skin layers, such as muscle, fascia, and bone, which is not specific to a full-thickness burn.

3. A 1-week-old infant has been in the pediatric unit for 18 hours following placement of a spica cast. The nurse observes a respiratory rate of fewer than 24 breaths/min. No other changes are noted. Because the infant is apparently well, the nurse does not report or document the slow respiratory rate. Several hours later, the infant experiences severe respiratory distress and emergency care is necessary. What should be considered if legal action is taken?

• A. Most infants have slow respirations when they are uncomfortable.
• B. The respirations of young infants are irregular, so a drop in rate is unimportant.
• C. Vital signs that are outside the expected parameters are significant and should be documented.
• D. The respiratory tract of young infants is underdeveloped, and their respiratory rate is not significant.

Correct answer: C

Rationale: In this scenario, the correct answer is C. Any vital signs outside the expected range in an infant should be documented and reported, as they may indicate a developing condition that requires prompt attention. Choice A is incorrect because slow respirations in infants should not be dismissed without assessment and documentation. Choice B is incorrect because a drop in respiratory rate in this case was significant and should have been documented. Choice D is incorrect because even though infants have underdeveloped respiratory tracts, any abnormal respiratory rate should be taken seriously and documented for monitoring and intervention if necessary.

4. The nurse caring for families in crisis assesses the affective function of an immigrant family consisting of a father, mother, and two school-age children. Based on Friedman's structural functional theory, what defines this family component?

• A. Meeting the love and belonging needs of each member
• B. Teaching children how to function and assume adult roles in society
• C. Ensuring the family has necessary resources with appropriate allocation
• D. Involving the provision of physical care to keep the family healthy

Correct answer: A

Rationale: In Friedman's structural functional theory, the affective function of a family involves meeting the love and belonging needs of each member. This includes emotional support, care, and connections that contribute to the overall well-being of the family unit. Choice B is incorrect as it pertains more to the socialization function of the family, where children learn societal roles. Choice C relates to the economic function of the family, ensuring resources are available and allocated appropriately. Choice D focuses on the instrumental function of the family, which involves meeting the physical needs and health of its members.

5. What factor predisposes the urinary tract to infection in children?

• A. increased fluid intake
• B. short urethra in young girls
• C. prostatic secretions in males
• D. frequent emptying of the bladder

Correct answer: B

Rationale: The short urethra in young girls predisposes them to urinary tract infections. In young girls, the proximity of the urethra to the anus and the shorter urethra compared to boys make it easier for bacteria to travel up the urinary tract, increasing the risk of infection. Increased fluid intake and frequent emptying of the bladder are actually helpful in preventing urinary tract infections by flushing out bacteria. Prostatic secretions in males are not a factor in predisposing the urinary tract to infection in children.

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